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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Wed: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: I K Page 4 of Facility Address: City: inspect') i Date k -2 0 FA #: 5-2, PR M Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1,320 gallons in tanks* and containers`*. Complete one box for each tank or each cumulative container product type. Tank (2820) El Containers, (282 1) #of Containers: TA#: 1 Total Capacity: gallons Product Type: (per tank or cumulative for corrfaiws by product type) Install Date: = Oank (2820) ❑ Containers (2821) #of Containers: TA#: L9 l31e& 2 Total Capacity: gallons Product Type: �/�f S p 7 (per tank or cumulative for cor1lainers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#; 3 Total Capacity: �� gallons Product Type: 1 (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: _ j) 4 Total Capacity: 2- gallons Product Type (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: C gallons Total Capacity for Site: gallons Comments: EHD Inspector:Reviewed By Initial: Date: <Entered Date: By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08